Health and the post-2015 development agenda: Stuck in the doldrums?

I think it’s fair to say most of us don’t typically take UN reports with us on our summer vacation. But you might want make an exception in the case of the high-level panel (HLP) report on the post-2015 development agenda. It offers a nice opportunity to reflect how – over the last 15 years or so – we have seen some serious global shifts in values, expectations and motivations.

The HLP feels the MDGs were worthwhile: “the MDGs set out an inspirational rallying cry for the whole world”. As my colleague Varun Gauri argues, goals inspire if they are underpinned by a moral case, and the panel pushes hard on issues of rights and responsibilities, social justice, and fairness: “new goals and targets need to be grounded in respect for universal human rights”; “these are issues of basic social justice. Many people living in poverty have not had a fair chance.”

The HLP realize we’re an ambitious generation, keen to leave our mark on the world, and unafraid of being bold. So they say: “After 2015 we should move from reducing to ending extreme poverty, in all its forms. … We can be the first generation in human history to end hunger and ensure that every person achieves a basic standard of wellbeing. There can be no excuses.”

The panel picks up on our growing commitment to universalism. It urges us to “leave no one behind” and “bring about more social inclusion”. The panelists say we need to do better on this than last time: “We should ensure that no person – regardless of ethnicity, gender, geography, disability, race or other status – is denied universal human rights and basic economic opportunities. We should design goals that focus on reaching excluded groups, for example by making sure we track progress at all levels of income.”

But universalism, says the HLP, means more that. The goals need to be broadly relevant – not just applicable to a few countries. And we need to realize that development goals are a shared responsibility – sustainable development is as much about what happens in North as what happens in the South.

All of this inevitably leads to a broader and more demanding set of goals – more topics, greater ambition, and more detail. The HLP feel the world wants this, and it’s probably right.

Which is why the report’s lackluster treatment of health comes as such a disappointment. It’s as if the teams working on the other topics got off to a great start in the post-2015 development goal “race” and never looked back, while the health team got stuck in the doldrums soon after the start, and the race organizers never thought to go and rescue them.

Disappointment in numbers

You can see what I mean from the two charts below.

Fig 1 is a frequency distribution of nouns occurring in the main body of the report – the more frequently the word is used, the larger its size. (I dropped “development”, “partnership” and “goals” which are used a lot but aren’t topical.) If you look really hard, you can just see “health” – sandwiched between the much larger “business” and “growth”. Just below “health” is the much larger “education” and a little below that is the even larger “energy”. Even “food” is bigger than “health”.

Figure 1: How often are different nouns used in the HLP report on the post-2015 development goals?

For Fig 2 I laid side by side – as best as I could – the new and old targets for the various MDG and post-2015 goals: tackling poverty, promoting gender quality, etc. (I used the new post-215 numbering.) I then counted the number of characters used in the text of each target and aggregated up to the level of the goal.

You can see in Fig 2 the expansion of the scope of the exercise, with in effect three new goals – 7, 10, and 11. You can also see how much more detail there is in the post-2015 goals than the MDGs. For example, the poverty MDG targets were described in just 96 characters; the post-2015 poverty targets take 440 characters to describe. This is true of all the goals except one: health. In this case there was actually a reduction in the number of characters – from 438 to 433. In fact, this is an undercount, because MDG target 8e (a shared global responsibility target) was “provide access to affordable essential drugs in developing countries”, and there is no new target on affordable drugs.

Figure 2: How many characters does it take to describe a development goal? MDGs vs. post-2015 goals

A not-so-great leap forward

The changes in Fig 2 reflect the increased ambitiousness and scope of the targets. For example, in the case of poverty, the $1.25-a-day target has been turned into a zero target (no extra characters for this part) but has also been supplemented by a target based on the national poverty line. In addition, three other targets have been added, one on rights to land, property, and other assets, another on social protection systems, and a third on building resilience and reducing fatalities from natural disasters.

Table 1 below shows how the MDGs and post-2015 goals compare in the case of health. True there’s some added ambition – as with poverty, the post-2015 health goal includes a zero target. But otherwise they’re almost identical. A vaccination target has been added – hardly a great leap forward, given that childhood immunization was already a monitoring indicator in the MDGs. The only real hint of any new thinking is the addition of a target to “reduce … priority non-communicable diseases.” But it’s subsumed within an old target, and – coming right at the end of the list – looks very much like an afterthought.

Table 1: The health MDG’s and post-2015 targets compared

Not 1999

So you see what I mean about health being stuck in the doldrums. It’s almost as if in the last 15 years nothing changed in the health field.

In fact there has been change – huge change.

Even in the 2000’s the health MDG’s weren’t very relevant to large swathes of the developing world. But with the recent global burden of disease report, we now know that the old and new targets (for they’re much the same) are even less relevant. Not only do the targeted causes of death combined account for a smaller share of disability-adjusted life years lost (or DALYs) than they did in 1999; they now account for less than 50% of DALYs in all regions except sub-Saharan Africa, and even there the picture is changing fast. So in a report that is striving for development goals that have universal appeal, we have a set of health targets that have even less salience than they did in 2000.

At the very minimum, the HLP might have had a set of targets for unfinished MDG business (eliminating preventable infant and under-five deaths, etc.) and then a second set of targets around NCDs that would have relevance across the globe – including in the richer North.

The panel could have gone further and taken a leaf out of the education sector’s book. We don’t set targets for a population’s knowledge and skills, but rather focus on whether children are in school and learning while they’re there. By analogy we could usefully have some targets defined in terms of outputs of the health system – it’s not the only contributor to health outcomes, but it’s one that people rightly expect to make a large impact on health, and one that governments have considerable control over.

The health system also causes a lot of frustration in many countries. It’s odd that none of this appears to have come through in the HLP’s consultations, because it came up a lot in the World Bank’s Voices of the Poor consultations – in the first volume, the word “health” crops up 245 times. And the concerns expressed there about poor quality services are reinforced by careful empirical work that shows the huge variation in the quality of medical diagnosis advice in the developing world – work that gives us some ideas about how service quality targets might be framed.

What happened to affordability?

There’s another dimension that’s completely missing in the HLP’s treatment of health, and one that’s been a big driver of change in the health sector in the last 15 years: financial protection.

A common lament in Voices of the Poor was the fear of financial catastrophe that ensues when a family is struck by illness or death. One aspect of this is the cost of getting treatment, especially hospital treatment which – as I reported in another post – can be financially ruinous for a poor family. Governments know that this worries people. China’s government embarked on its health reforms in 2003 precisely in response to opinion polls that showed huge discontent over the unaffordability of medical care. The dramatic worldwide push over the last 10 years on universal health coverage – documented in a series of recent World Bank studies – was prompted in no small part by governments wanting to provide better financial protection to their citizens. This is all missing in the HLP report, despite the fact that indicators of financial protection in health have been around for some time.

Together we can

It’s not too late to modernize the health angle to the post-2015 agenda. The MDG targets continued to be refined and extended long after the 2000 Millennium Declaration. And we haven’t even got to a post-2015 declaration yet.

So while you’re reading the HLP report on your vacation, have a think about what might go into a revised version of the health goals, and jot down your ideas in the comments section below. Together we might be able to come up with a post-2015 health agenda that is modern, ambitious and genuinely universal. Who knows, perhaps the Let’s Talk Development editor will offer a book token for the best comment? That way even if you work a bit on this year’s vacation, you’ll be able to relax on next year’s with a nice book.

Comments

I agree that health was exceptionally disappointing - very like the MDG shopping list of donor priorities. While zero preventable mortality in every quintle could be transformative, the HLP faield to respond tpo teh calls for measuring improved health in all life stages and Universal Health Coverage that came though so strongly in the health consulation. I would like to see genuinely transformative attempt to deliver the right to health in ways which address the major causes of mortality and morbidity on a country by country basis and the importance of health as an achievable right for all, not a commodity for sale to the rich alone.

I agree - the absence of a target nullifies the lesson from the MDGs that what gets measured is more likely to get done. It also fails to respond to the danger of vertical investments that can undermine health systems, as we saw with the population and disease-specific focus of the MDGs.

The narrative of the HLP report aknowledges the importance of systems and UHC, yet the opportunity to translate this into action is missed. There needs to be a clear articulation of UHC through targets and indicators that drive equitable progress - through targets that specify gap reductions as well as aggregate progress, with disaggregated indicators.

We have been advocating for a target on both the intervention coverage and financial risk protection components of UHC. We need further discussion to establish some consensus on what these should be. Here might be a good place to start...

For financial protection, the rate and depth of impoverishment from health expenditures seem the best indicators, and an opportunity to also encourage more frequent and better quality of data. If more readily available annual estimates are wanted, then the proportion of total health expenditures that are out-of-pocket may be a more crude measure.

For coverage of interventions, ideally we'd have several tracer measures that respond to the burden and distribution of disease, to make it applicable to all contexts. If just one interventions is more politically viable, skilled birth attendance is often used as a proxy for health system strenth, but whether this is the best available measure is hotly debated. I would go further for proxies of other health system building blocks, such as the density of health workers (again this indicator could do with much improvement to truly capture whether an appropriately trained, supported, equipped and paid health worker is within reach of every person).

Figure 1 has quite a few mistakes, so its meaninfulness is in doubt. You say that you have dropped "partnership" but it shows up in your Figure 1, under "poverty" . So, did you drop it? Also, why did you leave in other "nontopical" words like: access, progress, example, country, framework, and even time and today? All these words could mean a number of things with reference to aspirations for the new goals and so they obscure what you have set out to "measure" - the "relative unimportance" of health, I assume.

More serious, it is wrongheaded from you to gripe about the importance of food in Figure 1. People without food will not be healthy. You should perhaps be very alarmed about the size of the letters for "peace" as lack of peace is unquestionably very bad for health. There is little doubt that preventing disease is superior as a policy to financial protection in case of disease. Many of the larger words are for concepts that are really good for health. Even "education"!

What is a more inspirational goal :
1) healthy people who do not need health care OR
2) more costly healthcare systems tending to more ill people whose illness and injuries should have been prevented in the first place?

The first goal does not appear in the goals you set forth in the second half of the blog, especially when you argue that targets are needed "for outputs of the health system." From a social point of view the costs associated with such outputs are a deadweight loss when they refer to preventable diseases.

Figure 2 shows that there was much text about health earlier, and that this remains the case. It does not show that there is too little text about health. The emphasis on jobs , livelihoods and growth is to be welcome because progress on such indicators will make any necessary level of health care more affordable. And it may even directly improve mental health which is a large burden in the burden of disease studies you cite.

Thanks for the comment. On Fig 1, apologies -- I actually dropped "development", "agenda", "world" and "panel", and kept "partnership". Otherwise I left everything -- not sure where the other "mistakes" are. I didn't set out to prove anything actually -- the lack of focus on health didn't quite hit me until I saw the numbers. Yes, food, education and peace are good for health. So that means we should put less emphasis on health? And can we put a bit more if health is also good for education and growth? I don't see where this is going. And health systems are just about treating sick people? Not at all about preventing illness and managing NCDs?

Whereas it is appropriate to aim for an overall goal relating to improved health outcomes, this should have been accompanied by an ambitious goal that will hold the health sector to account for achieving this goal. In which case, Universal Health Coverage (UHC) fits the bill perfectly.

Everyone understands that the health sector contributes to health, primarily through people consuming effective health services. Therefore a goal which measures coverage of a broad range of preventive, curative, rehabilitative and palliative services would be appropriate. Unfortunately the HLP’s revamped MDG list isn’t adequate. Furthermore, from the US to the poorest countries in Africa, people recognise that one of the greatest barriers inhibiting coverage (and a major cause of poverty) is inadequate financial protection from health care costs. This should be reflected in the health system goal too.

UHC combines these two policy objectives very efficiently and across the world populations and politicians intuitively understand the concept of UHC. This is shown by people taking to the streets to protest specifically for UHC, either in terms of improved health services or better financial protection or frequently both. Just in the last month improved health coverage has been one of the main demands of protestors in Brazil, Spain and Indonesia. On the contrary you don’t see people taking to the streets demanding a 10% increase in healthy life expectancy.

Whereas the HLP report has disappointed many, for being so unambitious and not addressing health coverage, the good news is that other post-2015 processes are recognizing its relevance and importance. So for example, recently, the UN Global Compact, which represents the views of big international businesses chose UHC as its recommendation for a global health goal post 2015: http://www.unglobalcompact.org/docs/news_events/9.1_news_archives/2013_06_18/UNGC_Post2015_Report.pdf (see pages 14 and 15) Similarly the Leadership Council Report of the Sustainable Development Solutions Network has a strong emphasis on achieving UHC http://unsdsn.org/files/2013/06/130613-SDSN-An-Action-Agenda-for-Sustainable-Development-FINAL.pdf (see page 29). Finally, only last week, at the post-2015 Open Working Group meetings, many speakers , especially those from UN member states, identified UHC as an appropriate goal. This can be seen in this summary statement from the chairs: http://sustainabledevelopment.un.org/content/documents/3693cochairsconcluding.pdf

Establishing UHC as a development priority also reflects the policy objectives of some of the major agencies involved in health, not least WHO and the World Bank. For example when the President of the World Bank concluded his speech to the World Health Assembly in May he said:

“WE MUST BE the generation that delivers universal health coverage”

Many feel, this is a much more inspiring and relevant health goal for the generation steering development beyond 2015.

I agree with your concerns, and we will need more voices to add, to create the concophany need to change where we go after this latest "report".
I find you figures/ methods for evaluating humorous -much like listing whats for dinner by smelling the breezes from a restaurants kitchen. Granted that is not your problem, but rather the documents.
Continuing In the vein of pseudo analytics: Knowing a tweet is 140 chars max, the amount written on any one goal is roughly 3 tweets, and variants between less than a tweet. Pitiful no? - One can only say that this report,this DRAFT report, with xx.xx for numbers, can only, MUST only be the preliminary preamble for a much more detailed and comprehensive living set of documents. Defining the chapters and metrics, refraining from undue Utopian and political meandering shall be amazing in itself. Now where is the roadmap and timeline to do this?

It is apparent that "ensuring healthy lives" is really a product of all these goals put together - the so-called social, environmental and economic determinants of health. In that sense, Goal No 4 is misspecified - it really should mean what can health services do to deliver "healthy lives"? That being so, "Ensure UHC" would be a more appropriate goal were the HLP framework to be pursued or it could be reframed on the lines of Goal 6 "Achieve Universal Access to Health Services". Of course, the appropriateness of the five proposed targets needs to be further debated.

The HLP itself says "Though we focus on health outcomes in this goal, to achieve these outcomes requires universal access to basic healthcare."

It is apparent that "ensuring healthy lives" is a product of all the proposed goals - covering the so-called social, economic and environmental determinants of health. Viewed in that light Goal No 4 is misspecified. It should really mean what can be done in the "health sector" to "ensure healthy lives". The HLP as much as admitted this: "Though we focus on health outcomes in this goal, to achieve these outcomes requires universal access to basic healthcare."

Thus if the HLP framework is to be pursued further then Goal No 4 could be on the lines of Goal 6 "Achieve Universal Access to Health Services" or even "Achieve Universal Health Coverage". The proposed targets obviously require further debate.

Many thanks for this piece. I share your sentiments, and even mentioned you in a post I published on UHCForward a few days after the HLP report was released: http://uhcforward.org/blog/2013/jun/3/why-uhc-out-post-2015-goals

Many thanks for this piece and I completely agree that health has been left behind in the UNHLP report. As health was central to the MDGs with 3 out of the 8 MDGs on health outcomes it was surprising to see the lack of attention and focus placed on health now.

I understand that there is a strong push for UHC being the overarching health goal in the new post-2015 framework however I strongly believe the health goal should be focused on health outcomes that is underpinned by a sub set of health targets that will achieve the overarching goal. UHC will place health in the health sector only and not encourage a social determinants of health/multisectoral approach to health which is vital to ensure healthy lives.

This goal needs to reinforce health as a global concern for all countries, be ambitious, easily communicated, and serve to generate public interest and political leadership in health especially during a time where global health funding is going down.

The fact that NCDs are considered an afterthought in this report is shocking given the high burden of NCDs especially in low and middle income countries where health systems during the MDG era led to siloed approach to health and now lack strong health systems to tackle the double burden of disease--communicable and noncommunicable. Even though the narrative section of the health goal mentions NCDs, it describes it as a high-income country issue which evidence shows is no longer the case.

Finally, UHC should be seen as an enabler to acheiving the overarching health goal. As an enabler, UHC would avoid competition between diseases and provide focus for work on strong, integrated health systems with high-quality services, a well-trained, motivated and interdisciplinary health workforce, and available and equitably distributed medicines and technologies basically focusing on the health sector aspects of acheiving the overarching health goal.

The health system is also causes a lot of frustrations in many countries. That`s very great work that MDG targets continued to be refined long after the 2000 2000 millennium declaration.Keep posting such useful blog related to our heath system.

In developing post 2015 agenda, course of action and strategies, World Health Organization must play its crucial role, and it is time to stop playing as "World Disease Organization". Vertical programmes and disease focused interventions in developing countries have not been able to deliver the desired results. Therefor, a holistic approach based on the philosophy of Alma Ata must be revitalized. Health systems thinking ought to be employed taking into serious consideration the social determinants of health especially when it comes to health of the young girls, mothers and children under 5. States, development partners, NGOs and civil society must strengthen the community level grass root organizations and institute community governance, hence listening to their voices and needs.

In developing post 2015 agenda, course of action and strategies, World Health Organization must play its crucial role, and it is time to stop playing as "World Disease Organization". Vertical programmes and disease focused interventions in developing countries have not been able to deliver the desired results. Therefor, a holistic approach based on the philosophy of Alma Ata must be revitalized. Health systems thinking ought to be employed taking into serious consideration the social determinants of health especially when it comes to health of the young girls, mothers and children under 5. States, development partners, NGOs and civil society must strengthen the community level grass root organizations and institute community governance, hence listening to their voices and needs.